Tuberculosis of the cervix

822 Sections metastases.

LMERICAN of

the

JOURNAL

tubes

a.nd

OF OBSTETRICS AND GYNFKOLOGY

ovaries

present

no

abnormalities

and

no

evidence

of

In summary, therefore, this tumor of the body of the uterus is of the mixed type. Sarcomatous elements predominate. The bulk consists of nonstriated muscle cells intermingled with myxomatous tistue, osteoid and cartilage, all evidently derived from the parent mesenchymal substance. The glands focally encountered resemble those of the endometrial type. The glandular and stromal elements of the uterus, therefore, have been more or less reduplicated. In view of these findings, the tumors may be interpreted as arising from parent miillerian tissue. In closing I wish to extend my thanks to Dr. Gordon Gibson for permission to report this case; to Dr. Jean Oliver for his suggestions and to Mr. James V. Dunn, for his excellent photographs. REFERENCES Ewing, James : Neoplastic Geschwulstlehre, bed, Hugo : Emp. 35: 498, 1928. 1530

PRESIDENT

Diseases, p. 639.

ed. 2, W. B. Saunders, 1928, p. 962. Shaw, Wilfred: J. Obst. & Gynec.

STREET.

TIJBERCULOSIS WITH

BY EVERETTI;. (From

RibBrit.

the

Department

OF THE CERVIX

REPORT OF A CASE BISHOP,

of

M.D., ATLANTA,

Pathology,

Sthner

Cancer

GA. Clinic)

W

HILE the uterine cervix is perhaps somewhat susceptible to certain infections, tuberculosis is apparently very rare in this location. Whether it is actually as rare as statistics show may be a matter of doubt, for a number df cases were at first diagnosed as carcinoma, syphilis, etc. Carcinoma and tuberculosis may be present at the same time, making the diagnosis more difficult (v. Franque). However, it does appear that tuberculosis is really very rare, the number of cases confirmed by microscopic examination being comparatively few. Primary tuberculous infection of the cervix is exceedingly infrequent, there being less than 25 cases in this group. The condition could be assumed to be primary only in those cases in which no other organ was involved, and in which no hematogenous infection from another focus could take place. (Moore.) The great majority of reported cases have been secondary to tuberculosis elsewhere, especially the fallopian tubes, urinary or intestinal tract or lungs. Some authorities state that a fair percentage of women with pulmonary tuberculosis develop tuberculosis of the cervix, and that the secondary lesion is often unsuspected. (Williams.) In most cases, it is possible that the infection of the cervix follows by direct extension from the tubes, and some cases show evidence of this by the in-

BISHOP

:

TUBERCULOSIS

OF

THE

CERVIX

It is volvement of the intervening endometrium, rarely the myometrium. for the infection to involve the cervix without affecting the endometrium been shown in the experimental production of tuberculosis of the tubes. Bennecke; Hashimoto.)

The case which we are presenting here falls there was extensive destruction of tubes and change in the endometrium. It is doubtful if blood stream could be suspected in this case for in the body have been found. Some writers lay considerable an aid to differential diagnosis.

823 possible as has (Jung,

into this group, for cervix without any an extension by the no lesions elsewhere

stress on the age of the patient, as It is, however, of little diagnostic

Fig.

1.

significance, for carcinoma is being found in women under thirty years of age rather frequently. A personal or family history of tuberculosis, or a history of very long duration without the expected extension or metastases of carcinoma, would be of far greater diagnostic importance. Tuberculosis of the cervix usually presents itself as a polypoid mass, soon followed by ulceration. Both may be present simultaneously, or the mass may have disappeared and only ulceration remain. The appearance may be extremely ragged due to futile attempts at healing, or it may be sharply limited by fibrous tissue formation. On the other hand, the infection may be deep-seated, with very little destruction of the more superficial tissue. Secondary infection complicates the picture and hemorrhage usually occurs either at intervals or a steady oozing. The true miliary and fibrosing types are more unusual.

824

AMERICAN

JOURNAL

OF

OBSTETRICS

AND

GYNECOLOGY

The diagnosis of this condition must be made by microscopic examination and this may not always be easy, on account of the marked secondary infection usually present. Biopsy certainly does no harm in any ulcerating, bleeding, infected, fungating lesion, whether it be Frequent,ly the biopsy fails to carcinoma or of inflammatory origin. reach areas of typical tuberculosis, and in many cases the microscopic structure may be far from typical, leaving the diagnosis in doubt. Finding the tubercle bac,illi in the tissue clinches the diagnosis. CASE J.

H.,

:1 diagnosis

child,

aged

colored

f~m:~le,

of

eareinomr

fiftCCl1.

There

referred of

had

to the

the

ecrris.

been

no

REPORT fiteincr

Chnrer

The patient miscarriages

Fig

Clinic

in

was married and uo history

July,

1925,

and had of cancer

with

one or

2.

tuberculosis in her family. She ceased to menstruntc tffo years ago. She weighed 170 pounds, although she states that she had weighed as much as 215. She could not explain this loss of weight, which had been gradual, by any illness, and She Was a healthy looking woman. Her weight had been stationary for a considerable time. For the past two years, the patient had noticed a very slight bloody vaginal discharge, unaccompanied by any pain or discomfort. Physical examination was entirely ncgatire except for sligllt enlargement of one lobe of the thyroid. Pelvic examination reTealed an old lacerated cervix, with a partly ulcerated polypoid growth projecting from the est,ernal 0s. The body of the uterus was in normal position and not enlarged. The parametrium was negatire and there was no abdominal tenderness. The Wassermann was negative. Biopsy shoTTed a marked granulomatous inflammation with great numbers of lymphocytes, leucoeytes, and several atypical giant cells. Vasculnrity was abundant and there was cousidernble necrosis in certain areas. (Fig. 1.) A considerable amount of the secondary infection was cleared

BfSIIOP

:

TTJBEHCULOSIS

OF

THE

CERVI’IX

825

up by local treatment, and a second biopsy showed a more typical structure, with lymphoitl infiltration and giant cells considerable fibrosis, endothelial proliferation, (Fig. 2). A diagnosis of tuberculosis of the cervix was made. It was thought at this time that the condition might be a primary infection of the cervix on account of the absence of any evidence of disease elsewhere. shoncd a nmrkcd ulceration of the Hysterectomy was done and the uterus cervix extending into the lower part of the canal. Much of the cervix was The upper canal and the entire endometrium cdcmntous, hemorrhagic and friable. were entirely negative. The tubes were considerably swollen, injected and tightly adherent to tho uterine ~vall. No distinct tubercles could be seen on the outer surface of the tubes. The lumcrl of both tubes was tilled with light yelloaislr uccrotic mntcrinl. ~‘IW ov:,~+~~s vvorc smlll, firm, with numerous small cysts.

Fig.

3.

Microscopic examination of the cervix sholvcd the same structure as seen in the second biopsy. Examination of the tubes showed the lumen filled with necrotic material, and destruction of the mucosn, with numerous tubercles in the mucosa and submucosa. Most of the tuber&s were well rounded with central necrosis, lymphocytes, endothelial cells, and numerous giant cells (Fig. 3). While the remainder of the tube wall was edematous and very vascular, no actual tubercles were found beyond the submucosa, although cellular infiltration was quite marked. The diagnosis at this time was primary tuberculosis of the tubes with secondary involvement of the cervix. The patient made an uneventful recovery from the operation and nas last seen in January, 1927, at which t,irne there was no eridencc of discasc.

The interesting features of this case were (1) the apparent localized tuberculosis of the cervix without evidence of disease elsewhere; (2) the probable actual primary source of the infection discovered at operation; (3) involvement of the cervix from the tubes without evidence of the disease in either the uterine wall or endometrium.